Washwood Healthcare Service

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question as requires improvement. At this assessment the rating has improved to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff and people told us there was an inclusive and supportive environment which promoted dignity, respect, equality and safety. We found the service culture reflected compassion, kindness and commitment to supporting people to live their best lives as much as possible. Communication between people, staff and management was open, which supported transparency and trust.

Staff spoke highly of the registered manager and the provider and described their leadership as supportive and approachable. Staff were positive about how the registered manager and provider engaged the team in supporting people and making sure care reflected individual needs and preferences.

The provider demonstrated a clear shared direction and culture that placed people at the centre of their care. Conversations with the registered manager and provider showed they shared these values and were committed to making sure people were treated with dignity and respect. They recognised people as individuals and encouraged them to maintain their independence by doing as much as they were able for themselves. The provider and registered manager worked closely with people, their representatives and staff to maintain this shared direction that supported continuous learning and improvement.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodies the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders were visible and actively involved in the service. They were knowledgeable about people’s needs and the day‑to‑day running of the home and demonstrated a clear focus on delivering safe, effective, quality care. We saw the registered manager lead by example, modelling compassionate and inclusive behaviours, and promoting positive relationships. Staff told us they had confidence in the leadership of the home and described the registered manager and provider as responsive and felt supported to raise concerns or ask for guidance when needed.

Staff we spoke with said training equipped them with the knowledge and skills required to meet people’s individual needs. We saw training provided was appropriate and tailored to people’s health needs, including areas such as epilepsy, learning disability and diabetes awareness. One professional told us, “[Registered manager] is very proactive with training and staff interaction is really good, nothing is too much trouble [for staff].”

We saw evidence of regular staff supervisions and team meetings, demonstrating effective systems were in place to provide ongoing guidance, oversight and support to staff in their roles.

Staff treated people as individuals, people using the service told us staff knew them well. One staff member told us, “The staff work as a team. The manager also helps a lot and they [registered manager] will open their door to chat about any problem. We [staff] understand each other.” Everyone we spoke with said they knew the manager.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they would speak up and raise concerns when needed. One staff member said, “They [registered manager] will do an investigation [into concerns raised], and take action.” People and relatives also knew how to raise concerns, who they could raise their concerns with and felt confident doing so. People we spoke with knew who the registered manager was and felt they were approachable and available. This helped to ensure people felt confident to speak up and raise any concerns or feedback they may have.

The provider had a whistleblowing policy in place, and staff were aware of how to whistleblow and who to contact. Staff felt confident their concerns would be listened to and acted upon. When concerns were raised, the registered manager had responded sensitively and appropriately.

There were regular team and resident/relative meetings in place, providing opportunities for people and their relatives to share their views and raise concerns.

A complaints policy was in place and was available in an easy read format to support accessibility.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The registered manager and provider understood the importance of equality and worked to ensure staff were treated fairly and with respect, regardless of background or protected characteristics. Policies were in place to support equality, diversity and inclusion, and these were reflected in day‑to‑day practice.

Staff told us they felt supported and valued. We observed a diverse staff team who worked well together and spoke positively about their experience of working at the home. Staff had access to equality and diversity training, which helped reduce the risk of discrimination, bullying or harassment.

The provider shared with us opportunities staff had for development and progression. Some staff had been promoted from within the service and encouraged to progress into roles such as senior care assistants, which helped promote fairness and inclusion within the workforce. Reasonable adjustments had been made where needed to support staff in their roles.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. However, governance systems had not identified the issues around the medication, storage, and some policies were out of date and contained the incorrect legislation and guidance. These issues were discussed with the registered manager and provider and have since been updated and addressed, demonstrating openness and a willingness to improve.

The registered manager completed a range of audits to monitor quality, safety and performance, including audits of medicines, incidents, accidents, the home environment and fire safety. However, medication audits had not identified there was medication that should have been administered at a specific time before food; some medication was out of date; and no risk assessments were in place for people taking blood thinning medication. The registered manager took immediate action at the time of this assessment to address the issues we had identified.

Feedback from people living at the home and their relatives was gathered, learning from incidents, accidents and complaints. Where required, action plans were developed and used to drive improvement.

Discussions with the registered manager and the provider demonstrated they had a good understanding of regulatory requirements, including responsibilities around notifying CQC and the duty of candour. Accidents, incidents and near misses were reviewed at the time they occurred, and we saw evidence care plans and risk assessments were updated promptly to reflect any changes in people’s needs. This helped to mitigate the risk of reoccurrence and showed a responsive approach to risk management.

There were arrangements in place to support sustainability and business continuity. The service had a business continuity plan outlining how care would continue safely in the event of an emergency or significant disruption. Overall, governance and management arrangements supported the delivery of safe, effective and sustainable care.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Systems were in place to support collaborative working when people’s needs changed. Information was shared appropriately with external professionals and agency groups to support safe, coordinated care and positive outcomes for people.

We saw referrals had been made proactively, with recent involvement from dietitians, occupational therapists, community mental health team and GPs. This collaborative approach helped make sure people received timely, specialist support and care.

Staff and leaders communicated effectively with professionals and followed recommendations to improve people’s health and wellbeing.

People told us they were supported to access their local community and take part in activities which were important to them.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice.

There was a clear commitment to reviewing practice and identifying opportunities to improve people’s experiences and outcomes. Accidents and incidents were reviewed, and learning was shared with staff through daily handover and regular team meetings.

Staff were encouraged to speak up with ideas for improvement and felt confident these would be listened to.

The provider demonstrated a willingness to learn and improve by engaging with the other providers and the local authority. We saw evidence the service acted when concerns were raised and implemented recommended improvements. For example, the provider responded to feedback from CQC during this assessment by addressing the issues found with medication and some of their policies.